Dr. Munavalli is the medical director of the Goslen Aesthetic Skin Center in Charlotte, N.C. He represented the AADA on the Physicians EHR Coalition.

Every other month, Dermatology World covers technology issues in “Technically Speaking.” This month’s author, Gilly Munavalli, MD, MHS, is the medical director of the Dermatology, Laser, and Vein Specialists of the Carolinas, in Charlotte, N.C. He represented the AADA on the Physicians Electronic Health Record Coalition and previously wrote a column of the same name in Young Physician Focus.

By Gilly Munavalli, MD, MHS, August 01, 2012

Every article that I write on the process of adopting electronic health records (EHR) in my practice has therapeutic value. Each time I write, I realize, in the course of my research, that the problems we face aren’t unique to our practice, but challenge all of those who cross the digital divide of medical documentation. In my last article, I discussed who is able to input data into EHRs and touched on the structure of templates. Just as a good paper form can make all the difference in streamlining documentation at the point of care, an electronic template can facilitate the capture of all pertinent information to thoroughly capture all points of the HPI and physical exam to justify levels of E/M or CPT billing. A patient wants to add three other complaints to the visit, which may have been initially scheduled to evaluate a changing mole? With the properly designed template, no problem... I say bring it on.

Most EHRs have shortcuts, such as combo-boxes with search-on-first letter capability, checkboxes, keyboard shortcuts, and diagrams to help speed up data entry. Templates can be designed to take advantage of all these, as well as to spawn new notes that pull forward old patient encounter data to pre-populate the new encounter note.

Caution required

A danger of using an EHR, though, is that progress notes tend to take on a certain regularity or likeness. Carrying forward information from a previous visit should save precious time, ease documentation burdens, and benefit patient care by ensuring the details of an encounter are preserved. However, the challenge is to realize these benefits while not producing notes that are overly templated and uniform. We don’t want notes that appear to be duplicates of other notes.

For example, I still recall, from my residency experience in the Veterans Administration (VA) system, reviewing electronic notes on the VISTA system from other services. The patient notes from five to 10 visits prior to the current visit were all exactly identical, each one just copied and pasted forward, again and again. This is an easy trap to fall into when one considers that in private and academic dermatology practice, we are pressured to see more and more patients in the same amount of time. In reality, we may see about 80 percent of the same diagnoses, over and over again, including acne, alopecia, full body exams, skin cancer/pre-cancers, and contact dermatitis. [pagebreak]

Although Medicare is obviously actively encouraging us to implement EHRs, the Office of Inspector General (OIG) included “identical notes” as an area of interest in its 2011 Work Plan. Recovery Audit Contractors (RAC) saw a good deal of identical notes from one patient visit to the next, and also saw portions of notes being copied from one clinician to another. Will we come under the RAC microscope for our documentation habits? It isn’t too far-fetched to say that it is a distinct possibility. Although dermatology is relatively new to the electronic documentation world, we are among the busiest of all outpatient specialties, and will generate an enormous volume of electronic notes in the future as EHR takes hold.

Avoiding the problem

We as busy clinicians might not realize it in the course of our day, but even how our own staffs use our EHRs could open us up to accusations of fraud or misrepresentation. If the documentation for routine nursing visits is copied, and unknowingly signed off on, that makes us responsible for the contents of those notes.

Other potential problems are caused by the copying and pasting of information from other notes; pulling information from another visit could cause coding and billing issues. In one scenario, the pulled information that becomes part of the record of the second visit could contain services provided only during the first visit. If that pulled information is used for coding, the physician could be paid twice for services performed only once.

Taking shortcuts isn’t a crime. In most cases, we aren’t trying to beat the system, but just to get our work done and treat our patients and be able to move on and not get trapped at the office every night trying to document. But it’s important to understand that there are certain portions of the exam that we must review or create de novo every time. For example, if someone other than the billing provider documents these portions of the history, the provider must review that with the patient in order to get credit. And, past history copied from a previous record needs to be reviewed, not simply dropped into the note. Only the billing provider may sign off as documenting or reviewing the History of the Present Illness (HPI).

Copied notes also obscure the very details our documentation is intended to illuminate. We have all been in those situations where we are thinking, “I have no earthly idea why this patient was sent to me,” or “What does the rheumatologist recommend? I can’t tell from this note because it is eight pages of gibberish about a review of systems that isn’t even pertinent to them.” This occurs because progress notes that have been cut-and-pasted together are very difficult to decipher, and do not tell a meaningful story about the patient’s condition and the treatment plan or clinical thinking. [pagebreak]

Getting it right

How can we enjoy the benefits of an EHR while avoiding the pitfalls of cloned notes? In an excellent article for Physicians Practice, Betsy Nicoletti outlined some guidelines I find helpful. She suggests that the review of systems (ROS) and past medical, family, and social history (PFSH) do not need to be duplicated in each note as long as the documentation includes evidence that these items were reviewed and updated by the physician. She suggests three ways to do so:

Describe new ROS or PFSH information in the current note or note that there has been no change since the previous visit.

Include the date and location of the previous ROS or PFSH in the current note.

Document that the physician confirmed a ROS or PFSH that was either filled out by the patient or by a staff member and supplemented it with his or her own findings.

Nicoletti goes on to give scenarios that specifically help us to avoid the “rubber stamp sign.” I think these suggestions can go a long way in helping all of us avoid the dangers of note cloning:

“Always document the history of the present illness based on the patient’s description that day — never copy it from a previous visit.

Only use review of systems categories that are relevant to that day’s visit. Avoid copying all of the ROS from a previous visit.

Only use past medical, family, and social history from a previous note if it is reviewed with the patient and relevant to that day’s visit.

Use normal templates with care, and edit these thoroughly.”

In conclusion, we all should strive to get to know our EHRs thoroughly, as painful as that might be. Why, you ask? That is the best way to save precious time and get us home to our families. Many features exist to help us accomplish this, even though they are not always obvious or intuitive. The old copy-and-paste mentality may have merit some of the time, but be wary of having your notes all look the same. One last pearl gleaned from Nicoletti’s article: Try removing the names from a sampling of notes about recent patient visits. If you ask other clinicians in your practice to review these notes, are they able to make appropriate treatment decisions based on them? Are the notes telling the story of the patient’s condition and treatment needs? If not, it’s time to rethink how you are electronically documenting.